糖皮质激素在治疗肾移植术后巨细胞病毒性重症肺炎中的作用

Therapeutic role of glucocorticoid in treating CMV severe pneumonia after kidney transplantation

目的探讨糖皮质激素在治疗肾移植术后巨细胞病毒(CMV)性重症肺炎中的作用。方法2002年1月至2004年10月发生肾移植后CMV性重症肺炎26例。选取2002年1月至2003年3月之间发病的12例为A组,2003年4月至2004年10月之间发病的14例为B组。发生CMV性重症肺炎后,A组治疗方案为:停用环孢素A(或他克莫司)和霉酚酸酯等免疫抑制剂,应用更昔洛韦等抗病毒药物,防治其它合并的感染,全身支持疗法,吸氧或呼吸机辅助通气等措施。B组除上述同样治疗措施外,还常规静脉应用甲泼尼龙(MP),起始剂量为120～150mg/d,3～5d后减量至80mg/d维持,当临床表现好转后再减量至40mg/d,应用时间为8～21d,平均12d。以后改为口服泼尼松维持。比较2组的治疗效果。结果A组应用呼吸机治疗9例(75%),其中死亡7例(58.33%),2例移植肾功能丧失,需透析治疗(16.67%);B组应用呼吸机治疗的4例(28.57%),其中死亡2例(14.29%),患者均无移植肾功能丧失。两组患者需用呼吸机治疗的几率和死亡率比较,B组均低于A组,差异均有统计学意义(P值分别为0.047和0.038)。B组患者中,均未出现激素相关的严重不良反应。结论应用适当剂量的甲泼尼龙,能有效减轻肾移植后CMV性重症肺炎的肺部炎症反应,并能减少因停用其它免疫抑制剂导致的移植肾排斥反应,降低死亡率和避免移植肾功能的丧失。

Objective To investigate the therapeutic role of glucocorticoid in treating cytomegalovirus （CMV） severe pneumonia after kidney transplantation. Methods Two groups of patients with CMV severe pneumonia after kidney transplantation were analyzed. The therapeutics for 12 patients of group A included the elimination of immunosuppressive agents such as cyclosporine （or tacrolimus） and cellcept, the use of antiviral drug such as gancyclovir, measures to prevent and cure other bacterial and fungal infections, supportive therapies and suck of oxygen or mechanical ventilation by respirators. Except for the above therapies, methylprednisolone was routinely injected to those 14 patients of group B. At the beginning, the dose of methylprednisolone was 120 mg/day to 150 mg/day. Three to five days later, the dose was decreased to 80 mg/day. The dose was further decreased to 40 mg/day when patients＇ signs were improved. After patients＇ signs were excluded, prednisone was taken orally in place of methylprednisolone. In our patients, methylprednisolone was used for average 12 days, ranging from 8 to 21 days. Results Among the patients of group A, 9 （75 %） were treated with mechanical ventilation by respirators, 7 （58.33 %） died and 2 （16.67 %） received dialysis due to dysfunction of the transplanted kidneys. Among the patients of group B, 4 （28.57 %） were treated with mechanical ventilation by respirators, 2 （14.29 %） died and no case with the transplanted kidney loss was found. There were significant differences between the two groups on the probability of using mechanical ventilation by respirators and the mortality （P=0.047 and P=0.038 respectively）. In the patients of group B, no severe side effects caused by methylprednisolone were found. Conclusion The treatment with proper dose of methylprednisolone may extenuate effectively the inflammatory reaction from the CMV severe pneumonia after kidney transplantation while reduce the rejection related to the absence of other immunosuppressants and decrease the mortality and the rate of transplanted kidney loss.